Ratiu Adrian C, Crisan Doru C
Department of Obstetrics and Gynecology, University of Medicine and Pharmacy "Victor Babes", Timisoara, Romania.
Medicine (Baltimore). 2018 Nov;97(46):e13253. doi: 10.1097/MD.0000000000013253.
The rising tendency of cesarean sections will lead invariably to more complications such as placenta praevia. The aim of our study was to evaluate the utility of parallel vertical compression suture to preserve uterus in cases of placenta praevia, and to propose a rational approach of these problematic cases, according to their grade of myometrial invasion.We prospectively included 95 consecutive cases diagnosed with placenta praevia (group1 [Gr1]) where we used parallel compression suture and compared to retrospectively analyzed 100 consecutive cases managed without using this technique (group 2 [Gr2]). We differentiated the types of placenta praevia according to their invasion in myometrium because this parameter appreciates best their degree of severity, so we had 4 Grs: simple praevia (no adherent), accreta, increta, and percreta. All patients underwent ultrasound evaluation before surgery. Cesarean section was planned at 35 to 36 weeks. The main goal was to preserve the uterus whenever was possible. After opening the peritoneal cavity, we first inspected the lower segment and bladder. If no signs of engorged and tortuous vessels we dissected first the bladder and then performed a transverse hysterotomy, removed the placenta and placed 2 parallel vertical sutures on the lower segment below the hysterotomy incision through the entire thickness of both uterine walls. In cases of massively engorged vessels we dissected the bladder after infant delivery and made a transverse uterine incision slightly higher. We measured the amount of blood loss and performed three postoperative ultrasound exams, on day 2, 4 and at 6 to 8 weeks.Using this technique, we were able to preserve the uterus in 98.33% of Gr1 versus 78.47% from Gr2 of simple placenta praevia, in 88.23% in Gr1 compared to 42.86% in Gr2 of placenta accreta, only in 14.28% of increta type and in none (0%) of the 2 cases with placenta percreta.The simplified compression technique for hemostasis and preserving uterus in cases of simple placenta praevia and accreta is easy to perform without special surgical skills and is rapid. There are no short and long-time complications related to the technique. In cases of placenta increta the problem is not that this technique is unsuccessful but getting to that point to place the sutures is difficult. In severe cases of placenta percreta, unfortunately, the hysterectomy remains the treatment of choice.
剖宫产率的上升趋势必然会导致更多并发症，如前置胎盘。我们研究的目的是评估平行垂直压迫缝合术在前置胎盘病例中保留子宫的效用，并根据子宫肌层浸润程度对这些疑难病例提出合理的处理方法。我们前瞻性纳入了95例连续诊断为前置胎盘的病例（第1组[Gr1]），在这些病例中我们使用了平行压迫缝合术，并与回顾性分析的100例未使用该技术的连续病例（第2组[Gr2]）进行比较。我们根据前置胎盘侵入子宫肌层的情况对其类型进行区分，因为该参数最能体现其严重程度，所以我们分为4组：单纯前置胎盘（无粘连）、胎盘植入、穿透性胎盘植入和完全性穿透性胎盘植入。所有患者在手术前均接受超声评估。计划在孕35至36周行剖宫产。主要目标是尽可能保留子宫。打开腹腔后，我们首先检查子宫下段和膀胱。如果没有充血迂曲血管的迹象，我们先分离膀胱，然后行横切口子宫下段剖宫产术，取出胎盘，并在子宫下段剖宫产切口下方通过子宫壁全层放置2条平行的垂直缝线。在血管大量充血的情况下，我们在胎儿娩出后分离膀胱，并在稍高位置做一横切口子宫切开术。我们测量了失血量，并在术后第2天、第4天以及6至8周进行了三次超声检查。使用该技术，在单纯前置胎盘的病例中，第1组98.33%的患者子宫得以保留，而第2组为78.47%；在胎盘植入病例中，第1组为88.23%，第2组为42.86%；在穿透性胎盘植入类型中仅14.28%的患者子宫得以保留，2例完全性穿透性胎盘植入病例中无一例（0%）子宫得以保留。对于单纯前置胎盘和胎盘植入病例，这种简化的压迫止血及保留子宫的技术易于操作，无需特殊手术技能且迅速。该技术无短期和长期并发症。在穿透性胎盘植入病例中，问题不在于该技术不成功，而是到达放置缝线的时机很难。不幸的是，在严重的完全性穿透性胎盘植入病例中，子宫切除术仍是首选治疗方法。
